Cyclophosphamide in combination with immune therapeutics

ABSTRACT

The present invention relates to methods of treating a cancer and in particular, a B-cell derived cancer, using a lymphocytotoxic but hematopoeitic cell sparing high-dose pulsed amount of an oxazaphosphorine drug, either alone, or in combination with immune therapeutics such as, for example, monoclonal antibodies that selectively bind B-cell specific antigens.

BACKGROUND OF THE INVENTION

Cyclophosphamide and especially high-dose cyclophosphamide (for example, 50 mg/kg/day×4 days) has been used for the treatment of certain autoimmune diseases such as, for example, severe aplastic anemia. Low to intermediate doses of cyclophosphamide have also been used in combination chemotherapy for treating certain cancers and appears to work either by stopping the growth of cancer cells or by killing the cancer cells. However, usually remaining cancer cells, especially cancer stem cells, are able to divide, thereby leading to a relapse of the cancer.

More recently, immune-based therapeutics, for example, monoclonal antibodies targeted selectively to tumor specific antigens have been developed for treatment of various types of cancers. However, immune tolerance appears to be the major barrier to the effectiveness of most immune-based therapeutics. It has been reported that immune tolerance results largely from the integration of multiple regulatory mechanisms that have evolved to prevent the development of immunity to tumor specific antigens, which are perceived as self antigens instead of foreign antigens.

Therefore, there is a need to identify therapies or agents which may be used to break immune tolerance which severely limits the use of immune-based therapeutics in the treatment of cancer.

SUMMARY OF THE INVENTION

This invention is based, at least on part, on the discovery that, high-dose cyclophosphamide is effective in breaking immune tolerance which presents an obstacle in the use of various immune based therapeutics in the treatment of various types of cancers. The present invention provides methods of treating various cancers and, in particular, B-cell derived cancers, using high-dose pulsed amount of an oxazaphosphorine drug such as, for example, cyclophosphamide, either alone or in combination with other non-myeloablative therapies, such as, for example, monoclonal antibodies that selectively bind B-cell specific antigens such as, for example, CD-20 and CD-22.

In one aspect of the present invention, a method of eliminating or substantially reducing non-Hodgkin's lymphoma in a subject is provided. The method includes administering a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug to the subject, such that the subject's immune system reconstitutes without stem cell transplantation, thereby to eliminate or substantially reduce non-Hodgkin's lymphoma in the subject.

In another aspect of the present invention, a method for eliminating or substantially reducing Hodgkin's disease in a subject is provided. The method includes administering a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug to the subject, such that the subject's immune system reconstitutes without stem cell transplantation, thereby to eliminate or substantially reduce Hodgkin's lymphoma in the subject.

In yet another aspect of the present invention, a method for eliminating or substantially reducing chronic lymphocytic leukemia in a subject is provided. The method includes administering a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug to the subject, such that the subject's immune system reconstitutes without stem cell transplantation, thereby to eliminate or substantially reduce chronic lymphocytic leukemia in the subject.

In a further aspect of the present invention, a method for eliminating or substantially reducing mantle cell lymphoma in a subject is provided. The method includes administering a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug to the subject, such that the subject's immune system reconstitutes without stem cell transplantation, thereby to eliminate or substantially reduce mantle cell lymphoma in the subject.

In a further aspect of the present invention, a method for eliminating or substantially reducing multiple myeloma in a subject is provided. The method includes administering a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug to the subject, such that the subject's immune system reconstitutes without stem cell transplantation, thereby to eliminate or substantially reduce multiple myeloma in the subject.

In one or more aspects of the present invention, a method for eliminating or substantially reducing non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma in a subject includes administering a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug to the subject, such that the subject's immune system reconstitutes without stem cell transplantation, and administering an effective dose of a monoclonal antibody that selectively binds a B-cell specific antigen. A monoclonal antibody used in the methods of the invention may selectively bind an antigen chosen from: CD3d, CD5, CD6, CD9, CD19, CD20, CD21, CD22, CD23, CD24, CD27, CD28, CD37, CD38, CD40, CD45, CD46, CD48, CD53, CD69, CD70, CD72, CD73, CD79a, CD79b, CD80, CD81, CD83, CD85a, CD85d, CD85e, CD85h, CD85i, CD85j, CD85k, CD86, CD96, CD98, CD100, CD121b, CD124, CD127, CD132, CD150, CD152, CD154, CD157, CD166, CD169, CD179a, CD179b, CD180, CD185, CD196, CD197, CD205, CDw210a, CD213a1, CD257, CD267, CD268, CD269, CD274, CD275, CD276, CD278, CD279, CD300a, CD300c, CD307, CD314, CD316, CD317, CD319, CD320, CDw327, or CD331.

In some methods according to the present invention, a method for eliminating or substantially reducing non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma in a subject includes administering a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug to the subject, such that the subject's immune system reconstitutes without stem cell transplantation, and administering an effective dose of an antibody that selectively binds CD-20, thereby to eliminate or substantially reduce non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma in the subject.

In other methods according to the present invention, a method for eliminating or substantially reducing non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma in a subject includes administering a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug to the subject, such that the subject's immune system reconstitutes without stem cell transplantation, and administering an effective dose of an antibody that selectively binds CD-22, thereby to eliminate or substantially reduce non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma in the subject.

In some other embodiments, a lymphocytotoxic but hematopoeitic cell sparing high-dose pulsed amount of an oxazaphosphorine drug used in the methods described herein is between 100 mg/kg and 200 mg/kg, administered daily from 1 to 7 days. In other embodiments, a lymphocytotoxic but hematopoeitic cell-sparing high-dose pulsed amount of an oxazaphosphorine drug is between 25 mg/kg and 100 mg/kg, administered daily for 4 consecutive days. In some embodiments, a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug is administered to the subject for 4 days. In other embodiments, a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug is 50 mg/kg/day, administered for 4 days.

In various aspects of the methods of the present invention, the oxazaphosphorine drug is selected from the group consisting of cyclophosphamide, ifosfamide, perfosfamide, trophosphamide (trofosfamide), or a pharmaceutically acceptable salt, solvate, prodrug and metabolite thereof. In some embodiments, a oxazaphosphorine drug used in the methods described herein is cyclophosphamide or a pharmaceutically acceptable salt or metabolite thereof.

In still another aspect, the oxazaphosphorine drug is lyophilized cyclophosphamide or a pharmaceutically acceptable salt, solvate, prodrug, or metabolite thereof.

In some embodiments of the present invention, an effective amount of a monoclonal antibody that selectively binds a B-cell specific antigen is between about 100 mg/m² to about 200 mg/m². In other embodiments of the present invention, an effective amount of a monoclonal antibody that selectively binds a B-cell specific antigen is between about 200 mg/m² to about 300 mg/m², or between about 300 mg/m² to about 400 mg/m². In a particular embodiment, an effective amount of a monoclonal antibody that selectively binds a B-cell specific antigen is about 375 mg/m².

In one embodiment, a lymphocytotoxic hematopoeitic cell sparing high-dose pulsed amount of an oxazaphosphorine drug such as, for example, 50 mg/Kg of cyclophosphamide administered daily for 4 consecutive days, is administered to a subject having non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma, before the administration of an effective amount of a monoclonal antibody that selectively binds a B-cell specific antigen.

In another embodiment, a lymphocytotoxic hematopoeitic cell sparing high-dose pulsed amount of an oxazaphosphorine drug such as, for example, 50 mg/Kg of cyclophosphamide administered daily for 4 consecutive days, is administered to a subject having non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma, after the administration of an effective amount of a monoclonal antibody that selectively binds a B-cell specific antigen.

In yet another embodiment, an effective amount of a monoclonal antibody that selectively binds a B-cell specific antigen is administered to a subject having non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia or multiple myeloma both before and after administration of a lymphocytotoxic hematopoeitic cell sparing high-dose pulsed amount of an oxazaphosphorine drug such as, for example, 50 mg/Kg of cyclophosphamide administered daily for 4 consecutive days.

In some embodiments of the various aspects of the methods of the present invention, a subject having non-Hodgkin's lymphoma or Hodgkin's lymphoma or chronic lymphocytic leukemia or mantle cell lymphoma or multiple myeloma is further administered additional agents. Exemplary additional agents include, for example, hematopoeitic growth factors such as pegfilgrastin.

Also encompassed by this disclosure is a kit for treating non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma including: (a) a plurality of doses of a lymphocytotoxic but hematopoetic cell-sparing high-dose pulsed amount of a oxazaphosphorine drug; (b) a plurality of doses of an effective amount of one or more monoclonal antibodies that selectively bind a B-cell specific antigen; and (c) instructions for treating non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma using one or more doses of the oxazaphosphorine drug and one or more doses of one or more monoclonal antibodies that selectively bind a B-cell specific antigen, where the non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma disorder is treated without the need for stem cell transplantation.

In certain embodiments of the methods of the invention, the invention includes administering an effective amount of Mesna.

DETAILED DESCRIPTION OF THE INVENTION

The present invention is based, at least in part, on the discovery that a lymphocytotoxic high-dose pulsed amount of an oxazaphosphorine drug such as cyclophosphamide, can be used for breaking immune tolerance in a subject, which presents a major obstacle in the use of immunotherapeutics such as, monoclonal antibodies, in the treatment of various cancers and in particular, B-cell derived lymphomas. Such lymphomas are generally regarded as incurable with conventional therapies. Although, they may be responsive to conventional cytotoxic chemotherapy and radiation therapy, it appears that any remaining cancer cells and especially, cancer stem cells can result in a relapse of the cancer.

The present invention provides a method for eliminating or substantially reducing lymphomas including non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma and multiple myeloma in a subject by administering a lymphocytoxic but hematopoeitic stem-cell sparing high-dose pulsed amount of an oxazaphosphorine drug such as, for example, cyclophosphamide, such that the subject's immune system reconstitutes without stem cell transplantation.

In some embodiments, the present invention provides a method for eliminating or substantially reducing non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma in a subject by administering a lymphocytoxic but hematopoeitic stem-cell sparing high-dose pulsed amount of an oxazaphosphorine drug such as, for example, cyclophosphamide, such that the subject's immune system reconstitutes without stem cell transplantation, and administering an effective amount of a monoclonal antibody that selectively binds a B-cell specific antigen. It is understood that such antibodies are particularly effective in depleting B-cells including cancer stem cells which usually express B-cell specific antigens, thereby to eliminate or substantially reduce the lymphoma and incidence of a relapse.

One or more monoclonal antibodies that selectively bind a B-cell specific antigen may be administered either before the administration of a lymphocytoxic but hematopoeitic stem-cell sparing high-dose pulsed amount of an oxazaphosphorine drug such as, for example, cyclophosphamide, or one or more of antibodies that selectively bind a B-cell specific antigen may be administered after the administration of a lymphocytoxic but hematopoeitic stem-cell sparing high-dose pulsed amount of an oxazaphosphorine drug such as, for example, cyclophosphamide. In some embodiments, one or more monoclonal antibodies that selectively bind a B-cell specific antigen are administered to a subject both prior to and subsequent to the administration of a lymphocytoxic but hematopoeitic stem-cell sparing high-dose pulsed amount of an oxazaphosphorine drug such as, for example, cyclophosphamide.

In a particular embodiment, an effective amount of a monoclonal antibody that selectively binds a B-cell specific antigen such as, for example, rituximab, is administered to a subject having non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma, prior to the administration of a lymphocytoxic but hematopoeitic stem-cell sparing high-dose pulsed amount of an oxazaphosphorine drug such as, for example, cyclophosphamide, thereby resulting in a synergistic effect. For example, a synergistic effect may result from the sensitization of B-cells associated with a lymphoma to cytotoxic agents, where the B-cells are otherwise resistant to such agents, using a monoclonal antibody which selectively binds a B-cell specific antigen, and subsequently exposing the sensitized B-cells to a cytotoxic agent, e.g., a lymphocytotoxic but hematopoeitic cell sparing high-dose pulsed amount of an oxazaphosphorine drug. Accordingly, in some embodiments, a synergistic effect can be obtained by sensitizing B-cells by using a monoclonal antibody that selectively binds a B-cell specific antigen and subsequently exposing them to a lymphocytotoxic but hematopoeitic cell sparing high-dose pulsed amount of an oxazaphosphorine drug.

In some embodiments of the present invention, additional agents and in particular agents which facilitate hematopoeitic stem cell growth such as, for example, filgrastim and pegfilgrastin, are administered to a subject following the administration of a lymphocytoxic but hematopoeitic stem-cell sparing high-dose pulsed amount of an oxazaphosphorine drug such as, for example, cyclophosphamide.

In some aspects, the methods of the invention may further comprise administering an effective amount of Mesna.

I. Definitions

In order that the present disclosure may be more readily understood, certain terms are first defined. Additional definitions are set forth throughout the detailed description.

The term “an oxazaphosphorine drug” refers to a class of drugs which act as alkylating agents and cause immunoablation. They are generally highly cytotoxic and are often used as chemotherapeutic agents. Examples of oxazaphosphorine drugs include cyclophosphamide, ifosfamide, perfosfamide, trophosphamide (trofosfamide), and pharmaceutically acceptable salts, solvates, prodrugs and metabolites thereof. In some embodiments, an oxazaphosphorine drug used in the methods described herein is cyclophosphamide, which is sold under common trade-names including PROCYTOX®, CYTOXAN® and NEOSAR®. Cyclophosphamide is converted to 4-hydroxycyclophosphamide and its tautomer aldophosphamide in the liver and is cytotoxic to cells that express low levels of the enzyme aldehyde dehydrogenase, for example, NK cells and T and B lymphocytes. Ifosfamide (MITOXANA®) is a structural analog of cyclophosphamide and its mechanism of action is considered to be identical or substantially similar to that of cyclophosphamide. Perfosfamide (4-hydroperoxycyclophosphamide) and trophosphamide are also alkylating agents which are structurally related to cyclophosphamide. For example, Perfosfamide alkylates DNA, thereby inhibiting DNA replication and RNA and protein synthesis.

As used herein, the phrase “high-dose pulsed amount of an oxazaphosphorine drug” refers to a non-myeloablative amount of an oxazaphosphorine drug such as, for example, cyclophosphamide, which is immunoablative, upon single or multiple dose administration to a subject (such as a human patient suffering from non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma), thereby resulting in a substantial reduction in or complete elimination of mature circulating lymphocytes in the subject. In some embodiments, administration of a non-myeloablative amount of cyclophosphamide results in treating, preventing, curing, delaying, reducing the severity of, ameliorating at least one symptom of non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia or multiple myeloma, or prolonging the survival of the subject beyond that expected in the absence of such administration. In some embodiments, “high-dose pulsed amount of an oxazaphosphorine drug” refers to a dose of cyclophosphamide administered to a subject in need thereof, which results in eliminating or substantially reducing the number of circulating lymphocytes in the subject, including those which are associated with immune tolerance associated with cancer, while sparing the hematopoeitic progenitor stem cells. For example, in some embodiments, “high-dose pulsed amount of an oxazaphosphorine drug” is a 50 mg/kg/day dose of an oxazaphosphorine drug such as, for example, cyclophosphamide, administered to a subject in need thereof for 4 consecutive days.

The terms “eliminating,” “substantially reducing,” “treating,” and “treatment,” as used herein, refer to therapeutic or preventative measures described herein. The methods of “eliminating or substantially reducing” employ administration to a subject having non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma, a lymphocytotoxic non-myeloablative amount of an oxazaphosphorine drug such as, for example, cyclophosphamide, either alone or in combination with other non-myeloablative therapies, such as to prevent, cure, delay, reduce the severity of, or ameliorate one or more symptoms of non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma, thereby to prolong the survival of a subject beyond that expected in the absence of such treatment. In some embodiments, the term “eliminating” refers to a complete remission of a cancer, e.g., non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma in a subject treated using the methods described herein.

The term “hematopoeitic progenitor stem cell,” as used herein refers to any type of cell of the hematopoeitic system, including, but not limited to, undifferentiated cells such as hematopoeitic stem cells and progenitor cells, which are capable of reconstituting the immune system following administration of a lymphocytotoxic non-myeloablative amount of cyclophosphamide to a subject identified using the methods described herein.

The terms “immunoablation” and “immunoablative,” as used herein, refer to severe immunosuppression using a high-dose (i.e., lymphocytotoxic non-myeloablative amount) of cyclophosphamide, for example, 50 mg/kg×4 days of cyclophosphamide, which leads to substantial reduction in or elimination of the population of circulating lymphocytes, including for example, NK cells and B and T lymphocytes Immunoablation, as described herein, results in complete or substantially complete reduction in cells responsible for immune tolerance.

The term “lymphocytotoxic,” as used herein, refers to complete elimination of or substantial reduction in the number of circulating lymphocytes, including those associated with immune tolerance in a subject following administration of a high-dose (i.e., lymphocytotoxic non-myeloablative amount) of a oxazaphosphorine drug, such as, for example, 50 mg/kg×4 days of cyclophosphamide. The term “lymphocytotoxic,” includes killing of those immune cells by cyclophosphamide which express low levels of the enzyme aldehyde dehydrogenase.

The term “non-myeloablative,” as used herein, refers to a property of a compound such as, for example, an oxazaphosphorine drug such as cyclophosphamide, whereby the compound does not have a cytotoxic effect on myeloid cells, for example, hematopoeitic progenitor stem cells. In some embodiments, a non-myeloablative agent used in the methods described herein has a cytotoxic effect on the circulating mature lymphocytes (e.g., NK cells, and T and B lymphocytes) while sparing the progenitor cells, e.g., hematopoeitic progenitor stem cells that are capable of reconstituting the immune system. In some embodiments, a non-myeloablative agent used in the methods of the invention kills cells which express low levels of the enzyme aldehyde dehydrogenase (e.g., NK cells and B and T lymphocytes) while sparing cells which express high or resistant levels of the enzyme aldehyde dehydrogenase (e.g., hematopoeitic progenitor stem cells).

The terms “B lymphocyte” and “B cell,” as used interchangeably herein, are intended to refer to any cell within the B cell lineage as early as B cell precursors, such as pre-B cells B220⁺ cells which have begun to rearrange Ig VH genes and up to mature B cells and even plasma cells such as, for example, plasma cells which are associated with multiple myeloma. The term “B-cell,” also includes a B-cell derived cancer stem cell, i.e., a stem cell which is capable of giving rise to non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma. Such cells can be readily identified by one of ordinary skill in the art using standard techniques known in the art and those described herein.

The term “immune tolerance,” as used herein, refers to a condition in which an animal recognizes a particular cell or antigen(s) as self, which should be recognized as foreign. In other words, the animal's immune system fails to mount an immune response to a cell or antigen(s) because the antigen is recognized as self instead of foreign. For example, the animal fails to mount an immune response against an antigen which is specifically expressed on a cancer cell.

The terms “immunoglobulin” and “antibody” (used interchangeably herein) include a protein having a basic four-polypeptide chain structure consisting of two heavy and two light chains, said chains being stabilized, for example, by interchain disulfide bonds, which has the ability to specifically bind an antigen. The term “single-chain immunoglobulin” or “single-chain antibody” (used interchangeably herein) refers to a protein having a two-polypeptide chain structure consisting of a heavy and a light chain, said chains being stabilized, for example, by interchain peptide linkers, which has the ability to specifically bind an antigen. The term “domain” refers to a globular region of a heavy or light chain polypeptide comprising peptide loops (e.g., comprising 3 to 4 peptide loops) stabilized, for example, by β-pleated sheet and/or intrachain disulfide bond. Domains are further referred to herein as “constant” or “variable,” based on the relative lack of sequence variation within the domains of various class members in the case of a “constant” domain, or the significant variation within the domains of various class members in the case of a “variable” domain. Antibody or polypeptide “domains” are often referred to interchangeably in the art as antibody or polypeptide “regions.” The “constant” domains of an antibody light chain are referred to interchangeably as “light chain constant regions,” “light chain constant domains,” “CL” regions or “CL” domains. The “constant” domains of an antibody heavy chain are referred to interchangeably as “heavy chain constant regions,” “heavy chain constant domains,” “CH” regions or “CH” domains). The “variable” domains of an antibody light chain are referred to interchangeably as “light chain variable regions,” “light chain variable domains,” “VL” regions or “VL” domains). The “variable” domains of an antibody heavy chain are referred to interchangeably as “heavy chain constant regions,” “heavy chain constant domains,” “VH” regions or “VH” domains).

Immunoglobulins or antibodies can exist in monomeric or polymeric form, for example, IgM antibodies which exist in pentameric form and/or IgA antibodies which exist in monomeric, dimeric or multimeric form. Other than “bispecific” or “bifunctional” immunoglobulins or antibodies, an immunoglobulin or antibody is understood to have each of its binding sites identical. A “bispecific” or “bifunctional antibody” is an artificial hybrid antibody having two different heavy/light chain pairs and two different binding sites. Bispecific antibodies can be produced by a variety of methods including fusion of hybridomas or linking of Fab′ fragments. See, e.g., Songsivilai & Lachmann, (1990) Clin. Exp. Immunol. 79:315-321; Kostelny et al., (1992) J. Immunol. 148:1547-1553.

The term “antigen-binding portion” of an antibody (or “antibody portion”) includes fragments of an antibody that retain the ability to specifically bind to an antigen (e.g., a B-cell specific antigen). It has been shown that the antigen-binding function of an antibody can be performed by fragments of a full-length antibody. Examples of binding fragments encompassed within the term “antigen-binding portion” of an antibody include (i) a Fab fragment, a monovalent fragment consisting of the VL, VH, CL and CH1 domains; (ii) a F(ab′)₂ fragment, a bivalent fragment comprising two Fab fragments linked by a disulfide bridge at the hinge region; (iii) a Fd fragment consisting of the VH and CH1 domains; (iv) a Fv fragment consisting of the VL and VH domains of a single arm of an antibody, (v) a dAb fragment (Ward et al., (1989) Nature 341:544-546), which consists of a VH domain; and (vi) an isolated complementarity determining region (CDR). Furthermore, although the two domains of the Fv fragment, VL and VH, are coded for by separate genes, they can be joined, using recombinant methods, by a synthetic linker that enables them to be made as a single protein chain in which the VL and VH regions pair to form monovalent molecules (known as single chain Fv (scFv); see e.g., Bird et al., (1988) Science 242:423-426; and Huston et al., (1988) Proc. Natl. Acad. Sci. USA 85:5879-5883). Such single chain antibodies are also intended to be encompassed within the term “antigen-binding portion” of an antibody. Other forms of single chain antibodies, such as diabodies are also encompassed. Diabodies are bivalent, bispecific antibodies in which VH and VL domains are expressed on a single polypeptide chain, but using a linker that is too short to allow for pairing between the two domains on the same chain, thereby forcing the domains to pair with complementary domains of another chain and creating two antigen binding sites (see e.g., Holliger, P. et al., (1993) Proc. Natl. Acad. Sci. USA 90:6444-6448; Poljak, R. J. et al., (1994) Structure 2:1121-1123). Still further, an antibody or antigen-binding portion thereof may be part of a larger immunoadhesion molecule, formed by covalent or non-covalent association of the antibody or antibody portion with one or more other proteins or peptides. Examples of such immunoadhesion molecules include use of the streptavidin core region to make a tetrameric scFv molecule (Kipriyanov, S. M. et al., (1995) Human Antibodies and Hybridomas 6:93-101) and use of a cysteine residue, a marker peptide and a C-terminal polyhistidine tag to make bivalent and biotinylated scFv molecules (Kipriyanov, S. M. et al., (1994) Mol. Immunol., 31:1047-1058). Antibody portions, such as Fab and F(ab')₂ fragments, can be prepared from whole antibodies using conventional techniques, such as papain or pepsin digestion, respectively, of whole antibodies. Moreover, antibodies, antibody portions and immunoadhesion molecules can be obtained using standard recombinant DNA techniques, as described herein. Preferred antigen binding portions are complete domains or pairs of complete domains.

“Specific binding,” “specifically binds,” “selective binding,” and “selectively binds,” as used herein, mean that the compound, e.g., antibody or antigen-binding portion thereof, exhibits appreciable affinity for a particular antigen or epitope and, generally, does not exhibit significant cross-reactivity with other antigens and epitopes. “Appreciable” or preferred binding includes binding with an affinity of at least 10⁶, 10⁷, 10⁸, 10⁹ M⁻¹, or 10¹⁰ M⁻¹. Affinities greater than 10⁷ M⁻¹, preferably greater than 10⁸ M⁻¹ are more preferred. Values intermediate of those set forth herein are also intended to be within the scope of the present invention and a preferred binding affinity can be indicated as a range of affinities, for example, 10⁶ to 10¹⁰ M⁻¹, preferably 10⁷ to 10¹⁰ M⁻¹, more preferably 10⁸ to 10¹⁰ M⁻¹. An antibody that “does not exhibit significant cross-reactivity” is one that will not appreciably bind to an undesirable entity (e.g., an undesirable proteinaceous entity). For example, in one embodiment, an antibody or antigen-binding portion thereof, that specifically binds to a B-cell specific antigen, such as, for example, CD-20 or CD-22, will appreciably bind CD-20 or CD-22, but will not significantly react with other non-CD-20 or non-CD-22 proteins or peptides. Specific or selective binding can be determined according to any art-recognized means for determining such binding, including, for example, according to Scatchard analysis and/or competitive binding assays.

The term “humanized immunoglobulin” or “humanized antibody” refers to an immunoglobulin or antibody that includes at least one humanized immunoglobulin or antibody chain (i.e., at least one humanized light or heavy chain). The term “humanized immunoglobulin chain” or “humanized antibody chain” (i.e., a “humanized immunoglobulin light chain” or “humanized immunoglobulin heavy chain”) refers to an immunoglobulin or antibody chain (i.e., a light or heavy chain, respectively) having a variable region that includes a variable framework region substantially from a human immunoglobulin or antibody and complementarity determining regions (CDRs) (e.g., at least one CDR, preferably two CDRs, more preferably three CDRs) substantially from a non-human immunoglobulin or antibody, and further includes constant regions (e.g., at least one constant region or portion thereof, in the case of a light chain, and preferably three constant regions in the case of a heavy chain). The term “humanized variable region” (e.g., “humanized light chain variable region” or “humanized heavy chain variable region”) refers to a variable region that includes a variable framework region substantially from a human immunoglobulin or antibody and complementarity determining regions (CDRs) substantially from a non-human immunoglobulin or antibody.

The term “human antibody” includes antibodies having variable and constant regions corresponding to human germline immunoglobulin sequences as described by Kabat et al. (See Kabat, et al., (1991) Sequences of proteins of Immunological Interest, Fifth Edition, U.S. Department of Health and Human Services, NIH Publication No. 91-3242). The human antibodies of the invention may include amino acid residues not encoded by human germline immunoglobulin sequences (e.g., mutations introduced by random or site-specific mutagenesis in vitro or by somatic mutation in vivo), for example in the CDRs and in particular CDR3. The human antibody can have at least one position replaced with an amino acid residue, e.g., an activity enhancing amino acid residue which is not encoded by the human germline immunoglobulin sequence. The human antibody can have up to twenty positions replaced with amino acid residues which are not part of the human germline immunoglobulin sequence. In other embodiments, up to ten, up to five, up to three or up to two positions are replaced. In a preferred embodiment, these replacements are within the CDR regions as described in detail below.

The term “recombinant human antibody” includes human antibodies that are prepared, expressed, created or isolated by recombinant means, such as antibodies expressed using a recombinant expression vector transfected into a host cell, antibodies isolated from a recombinant, combinatorial human antibody library, antibodies isolated from an animal (e.g., a mouse) that is transgenic for human immunoglobulin genes (see e.g., Taylor, L. D. et al., (1992) Nucl. Acids Res. 20:6287-6295) or antibodies prepared, expressed, created or isolated by any other means that involves splicing of human immunoglobulin gene sequences to other DNA sequences. Such recombinant human antibodies have variable and constant regions derived from human germline immunoglobulin sequences (See Kabat E. A., et al., (1991) Sequences of Proteins of Immunological Interest, Fifth Edition, U.S. Department of Health and Human Services, NIH Publication No. 91-3242). In certain embodiments, however, such recombinant human antibodies are subjected to in vitro mutagenesis (or, when an animal transgenic for human Ig sequences is used, in vivo somatic mutagenesis) and thus the amino acid sequences of the VH and VL regions of the recombinant antibodies are sequences that, while derived from and related to human germline VH and VL sequences, may not naturally exist within the human antibody germline repertoire in vivo. In certain embodiments, however, such recombinant antibodies are the result of selective mutagenesis approach or backmutation or both.

An “isolated antibody” includes an antibody that is substantially free of other antibodies having different antigenic specificities (e.g., an isolated antibody that specifically binds a B-cell specific antigen and is substantially free of antibodies or antigen-binding portions thereof that specifically bind other antigens, including other B-cell antigens). An isolated antibody that specifically binds a B-cell specific antigen may bind the same antigen and/or antigen-like molecules from other species. Moreover, an isolated antibody may be substantially free of other cellular material and/or chemicals.

The term “chimeric immunoglobulin” or antibody refers to an immunoglobulin or antibody whose variable regions derive from a first species and whose constant regions derive from a second species. Chimeric immunoglobulins or antibodies can be constructed, for example by genetic engineering, from immunoglobulin gene segments belonging to different species.

II. Exemplary Disorders

Exemplary disorders which may be treated using the methods of the invention include cancer and in particular, B-cell derived cancers such as, for example, non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma and multiple myeloma. Additional B-cell derived cancers include, for example, B-cell prolymphocytic leukemia, lymphoplasmocytic leukemia, splenic marginal zone lymphoma, marginal zone lymphoma (extra-nodal and nodal), and follicular lymphoma (e.g., Grade I and II). In general, without intending to be bound by theory, it is contemplated that any cancer associated with the expression of a cancer-specific antigen may be treated using the methods of the invention. In some embodiments, a cancer treated using the methods of the present invention is a B-cell derived cancer associated with the expression of one or more B-cell specific antigens such as, for example, CD3d, CD5, CD6, CD9, CD19, CD20, CD21, CD22, CD23, CD24, CD27, CD28, CD37, CD38, CD40, CD45, CD46, CD48, CD53, CD69, CD70, CD72, CD73, CD79a, CD79b, CD80, CD81, CD83, CD85a, CD85d, CD85e, CD85h, CD85i, CD85j, CD85k, CD86, CD96, CD98, CD100, CD121b, CD124, CD127, CD132, CD150, CD152, CD154, CD157, CD166, CD169, CD179a, CD179b, CD180, CD185, CD196, CD197, CD205, CDw210a, CD213a1, CD257, CD267, CD268, CD269, CD274, CD275, CD276, CD278, CD279, CD300a, CD300c, CD307, CD314, CD316, CD317, CD319, CD320, CDw327, and CD331. In a particular embodiment, a cancer treated using the methods of the invention is associated with the expression of CD-20. In another embodiment, a cancer treated using the methods of the invention is associated with the expression of CD-22. In yet another embodiment, a cancer treated using the methods of the invention is associated with the expression of both CD-20 and CD-22.

In some embodiments, a cancer treated using the methods of the invention is non-Hodgkin's lymphoma or NHL. Non-Hodgkin's lymphoma or NHL, is a cancer of the lymphoid tissue which is formed by several types of immune cells including B-cells and T-cells. About 85% of the non-Hodgkin's lymphomas are derived from B-cells. NHL is thought to occur when B-cells, which produce antibodies, begin to grow abnormally. In some embodiments, non-Hodgkin's lymphoma treated using the methods of the invention is associated with the expression of CD-20 on B-cells. In other embodiments, non-Hodgkin's lymphoma is associated with the expression of CD-22. In yet other embodiments, non-Hodgkin's lymphoma is associated with the expression of both CD-20 and CD-22.

In some embodiments, a cancer treated using the methods of the invention is Hodgkin's lymphoma, also referred to as Hodgkin's disease. The cancer cells in Hodgkin's disease are called Reed-Sternberg cells, after the two doctors who first described them in detail. Under a microscope they look different from cells of non-Hodgkin's lymphomas and other cancers, and are believed to be a type of malignant B lymphocyte.

In some embodiments, a cancer treated using the methods of the invention is chronic lymphocytic leukemia (CLL) which is derived from a small B lymphocyte. CLL is mostly found in the blood and in the bone marrow.

In further embodiments, a cancer treated using the methods of the invention is mantle cell lymphoma.

In yet other embodiments, a cancer treated using the methods of the invention is multiple myeloma, associated with uncontrolled proliferation of antibody producing cells in the plasma, which develop from B-cells. Multiple myeloma is the second most common hematologic malignancy in the United States.

III. Exemplary Oxazaphosphorine Drugs

The methods of the present invention, are based, at least in part, on the discovery that high-dose pulsed amount of an oxazaphosphorine drug may be used for breaking immune tolerance, which presents a major obstacle in the use of immune therapeutics for the treatment of cancer such as, for example, monoclonal antibodies that bind cancer specific antigens.

Exemplary oxazaphosphorine drugs that may be used in the methods of the invention include, but are not limited to, for example, cyclophosphamide (CPA), ifosfamide (IFO), and trofosfamide, perfosfamide, or a pharmaceutically acceptable salt, solvate, prodrug and metabolite thereof. CPA is widely used in low to intermediate amounts as an anticancer drug, an immunosuppressant, and for the mobilization of hematopoetic progenitor cells from the bone marrow into peripheral blood prior to bone marrow transplantation for aplastic anemia, leukemia, and other malignancies. Additional oxazaphosphorine drugs that may be used in the methods of the invention include, for example, mafosfamide (NSC 345842), glufosfamide (D19575, beta-D-glucosylisophosphoramide mustard), NSC 612567 (aldophosphamide perhydrothiazine), and NSC 613060 (aldophosphamide thiazolidine).

Both CPA and IFO are prodrugs that require activation by hepatic cytochrome P450 (CYP)-catalyzed 4-hydroxylation, yielding cytotoxic nitrogen mustards capable of reacting with DNA molecules to form crosslinks and lead to cell apoptosis and/or necrosis. However, more newly synthesized oxazaphosphorine derivatives such as glufosfamide, NSC 612567 and NSC 613060, do not need hepatic activation. They are activated through other enzymatic and/or non-enzymatic pathways.

In some embodiments according to the present invention, an oxazaphosphorine drug is a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of cyclophosphamide.

IV. Exemplary Antibodies

In various methods of the present invention, cancers derived from B-cells can be treated using a combination of a high-dose pulsed amount of an oxazaphosphorine drug and a monoclonal antibody which selectively binds a B-cell specific antigen.

In some embodiments of the present invention, an antibody is a monoclonal antibody that specifically binds CD-20. In other embodiments, an antibody is a monoclonal antibody that specifically binds CD-22 on a B-cell. However, without wishing to be bound by theory, it is contemplated that a monoclonal antibody that selectively binds any one of B-cell specific antigens CD3d, CD5, CD6, CD9, CD19, CD20, CD21, CD22, CD23, CD24, CD27, CD28, CD37, CD38, CD40, CD45, CD46, CD48, CD53, CD69, CD70, CD72, CD73, CD79a, CD79b, CD80, CD81, CD83, CD85a, CD85d, CD85e, CD85h, CD85i, CD85j, CD85k, CD86, CD96, CD98, CD100, CD121b, CD124, CD127, CD132, CD150, CD152, CD154, CD157, CD166, CD169, CD179a, CD179b, CD180, CD185, CD196, CD197, CD205, CDw210a, CD213a1, CD257, CD267, CD268, CD269, CD274, CD275, CD276, CD278, CD279, CD300a, CD300c, CD307, CD314, CD316, CD317, CD319, CD320, CDw327, or CD331, may be used in the methods of the invention. It is also contemplated that any antibody that results in depletion or substantial reduction in the number of B-cells in a sample, or has significant activity in assays for antibody dependent cellular cytotoxicity (ADCC), such as, for example, rituximab, may be used in the methods of the invention.

Commercially available monoclonal antibodies that specifically bind B-cell specific antigens include rituximab, which binds CD-20, and epratuzumab, which binds CD-22.

Antibodies or antigen-binding portions thereof can be tested for binding to a B-cell or a B-cell specific antigen by, for example, standard assays known in the art, such as ELISA, FACS analysis and/or Biacore analysis.

Antibodies or antigen-binding portions useful in the methods of the invention may be labeled with a detectable substance using well known techniques. Suitable detectable substances include various enzymes, prosthetic groups, fluorescent materials, luminescent materials and radioactive materials. Examples of suitable enzymes include horseradish peroxidase, alkaline phosphatase, β-galactosidase, or acetylcholinesterase; examples of suitable prosthetic group complexes include streptavidin/biotin and avidin/biotin; examples of suitable fluorescent materials include umbelliferone, fluorescein, fluorescein isothiocyanate, rhodamine, dichlorotriazinylamine fluorescein, dansyl chloride or phycoerythrin; an example of a luminescent material includes luminol; and examples of suitable radioactive material include ¹⁴C, ¹²³I, ¹²⁴I, ¹²⁵I, ¹³¹I, ^(99m)Tc, ³⁵S or ³H.

IV. Modes Of Administration

The various compounds used in the methods described herein may be administered orally, parenterally (e.g., intravenously), intramuscularly, sublingually, buccally, rectally, intranasally, intrabronchially, intrapulmonarily, intraperitonealy, topically, transdermally and subcutaneously, for example. The amount of compound administered in a single dose may dependent on the subject being treated, the subject's weight, the manner of administration and the judgment of the prescribing physician. Generally, however, administration and dosage and the duration of time for which a composition is administered will approximate that which are necessary to achieve a desired result.

For example, in some embodiments, a lymphocytotoxic non-myeloablative amount of a oxazaphosphorine drug used in the methods described herein is between 100 mg/kg and 200 mg/kg, administered daily from 1 to 7 days. In other embodiments, an effective amount of a lymphocytotoxic non-myeloablative amount of a oxazaphosphorine drug is between 25 mg/kg and 100 mg/kg, administered daily for 4 consecutive days. In yet other embodiments, a lymphocytotoxic non-myeloablative amount of a oxazaphosphorine drug is 50 mg/kg administered daily for 4 consecutive days.

In general, a therapeutically effective amount of a monoclonal antibody such as, for example, an antibody that specifically binds CD-20 or CD-22, from about 0.0001 mg/Kg to 0.001 mg/Kg; 0.001 mg/kg to about 10 mg/kg body weight or from about 0.02 mg/kg to about 5 mg/kg body weight. In some embodiments, a therapeutically effective amount of a monoclonal antibody is from about 0.001 mg to about 0.01 mg, about 0.01 mg to about 100 mg, or from about 100 mg to about 1000 mg, for example.

In some embodiments, an effective amount of an antibody administered to a subject having -Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia or multiple myeloma between about 100 mg/m² and 200 mg/m², or between about 200 mg/m² and 300 mg/m² or between about 300 m g/m² and 400 mg/m². In a particular embodiment, an effective amount of a monoclonal antibody that selectively binds a B-cell specific antigen is about 375 mg/m².

The dose for the oxazaphosphorine drug, e.g., cyclophosphamide, for use in the methods of the present invention can be calculated according to the ideal body weight of the subject. Ideal body weight can be determined, for example, according to Metropolitan Life tables, or any other standard known in the art. If the patient's actual body weight is less than ideal, the actual weight may be used for the calculation of the oxazaphosphorine drug dose.

The optimal pharmaceutical formulations for a desired monoclonal antibody can be readily determined by one or ordinary skilled in the art depending upon the route of administration and desired dosage. (See, for example, Remington's Pharmaceutical Sciences, 18th Ed. (1990), Mack Publishing Co., Easton, Pa., the entire disclosure of which is hereby incorporated by reference).

Antibodies for use in the methods or compositions described herein can be formulated for the most effective route of administration, including for example, oral, transdermal, sublingual, buccal, parenteral, rectal, intranasal, intrabronchial or intrapulmonary administration.

In some embodiments, the present invention provides kits including one or more doses of high-dose pulsed amount of an oxazaphosphorine drug and/or one or more doses of an immune therapeutic such as, for example, a B-cell specific monoclonal antibody, packaged with instructions of use. Such instructions may pertain to use of the packaged components (i.e., one or more doses of a high-dose pulsed amount of an oxazaphosphorine drug and one or more doses of a B-cell specific monoclonal antibody) in methods of treating, preventing, ameliorating, eliminating or substantially reducing Hodgkin's lymphoma, non-Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma, in a patient, or a symptom associated with Hodgkin's lymphoma, non-Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma in a patient, by administering the one or more doses of high-dose pulsed amount of an oxazaphosphorine drug and/or one or more doses of a B-cell specific monoclonal antibody.

Depending on the intended mode of administration, the compounds used in the methods described herein may be in the form of solid, semi-solid or liquid dosage forms, such as, for example, tablets, suppositories, pills, capsules, powders, liquids, suspensions, lotions, creams, gels, or the like, preferably in unit dosage form suitable for single administration of a precise dosage. Each dose may include an effective amount of a compound used in the methods described herein in combination with a pharmaceutically acceptable carrier and, in addition, may include other medicinal agents, pharmaceutical agents, carriers, adjuvants, diluents, etc.

Liquid pharmaceutically administrable compositions can prepared, for example, by dissolving, dispersing, etc., a compound for use in the methods described herein and optional pharmaceutical adjuvants in an excipient, such as, for example, water, saline aqueous dextrose, glycerol, ethanol, and the like, to thereby form a solution or suspension. For solid compositions, conventional nontoxic solid carriers include, for example, pharmaceutical grades of mannitol, lactose, starch, magnesium stearate, sodium saccharin, talc, cellulose, glucose, sucrose, magnesium carbonate, and the like. If desired, the pharmaceutical composition to be administered may also contain minor amounts of nontoxic auxiliary substances such as wetting or emulsifying agents, pH buffering agents and the like, for example, sodium acetate, sorbitan monolaurate, triethanolamine sodium acetate, triethanolamine oleate, etc. Actual methods of preparing such dosage forms are known, or will be apparent, to those skilled in this art; see, for example, Remington's Pharmaceutical Sciences, 18th Ed. (1990), Mack Publishing Co., Easton, Pa., the entire disclosure of which is hereby incorporated by reference).

V. Methods Of Treatment

Methods of treatment described herein encompass methods of eliminating or substantially reducing a B-cell derived cancer such as, for example, non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma and multiple myeloma. Also encompassed are methods of eliminating immune cells which are capable of eliciting immune tolerance and methods of depleting cancer stem cells. All methods described herein exclude the use of stem cell transplantation.

A subject having non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma can be diagnosed using standard techniques known in the art. For example, a diagnosis may be made by removing a part of a lymph node and examining the cells under a microscope. Biopsies may also be taken from other body tissues.

Subsequent to the diagnosis of a subject as having non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma, the subject can be treated using methods of the invention, thereby to eliminate or substantially reduce non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma in the subject.

In some embodiments, a subject having non-Hodgkin's lymphoma or Hodgkin's lymphoma or chronic lymphocytic leukemia or mantle cell lymphoma or multiple myeloma is administered a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug, e.g., 50 mg/kg of cyclophosphamide administered each day for 4 days. In other embodiments, a subject having non-Hodgkin's lymphoma or Hodgkin's lymphoma or chronic lymphocytic leukemia or mantle cell lymphoma or multiple myeloma is administered a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug, e.g., 50 mg/kg of cyclophosphamide for 4 days, followed by a therapeutically effective amount of a monoclonal antibody which specifically binds a B-cell specific antigen, e.g., CD-20 or CD-22.

In some embodiments, a subject having non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma is administered a monoclonal antibody that selectively binds a B-cell specific antigen prior to the administration of a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug, e.g., cyclophosphamide. In other embodiments, a subject having non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma is administered a monoclonal antibody that selectively binds a B-cell specific antigen subsequent to the administration of a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug, e.g., cyclophosphamide. In yet other embodiments, a subject having non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma is administered a monoclonal antibody that selectively binds a B-cell specific antigen both prior and subsequent to the administration of a lymphocytotoxic but hematopoeitic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug, e.g., cyclophosphamide.

In some methods of treatments, according to the invention, a method of eliminating or substantially reducing non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma in a subject includes (a) administering a lympocytoxic but hematopoeitic cell sparing high dose pulsed amount of an oxazaphosphorine drug, such that the subject's immune system reconstitutes without stem cell transplantation; (b) administering a therapeutic amount of an antibody that specifically binds a B-cell specific antigen; and (c) administering a therapeutic amount of an idiotypic vaccine, thereby to eliminate or substantially reducing non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma or multiple myeloma in the subject.

The specification is most thoroughly understood in light of the teachings of the references cited within the specification which are hereby incorporated by reference. The embodiments within the specification provide an illustration of embodiments in this disclosure and should not be construed to limit its scope. The skilled artisan readily recognizes that many other embodiments are encompassed by this invention. All publications and patents cited and sequences identified by accession or database reference numbers in this disclosure are incorporated by reference in their entirety. To the extent that the material incorporated by reference contradicts or is inconsistent with the present specification, the present specification will supercede any such material. The citation of any references herein is not an admission that such references are prior art to the present disclosure.

Unless otherwise indicated, all numbers expressing quantities of ingredients, cell culture, treatment conditions, and so forth used in the specification, including claims, are to be understood as being modified in all instances by the term “about.” Accordingly, unless otherwise indicated to the contrary, the numerical parameters are approximations and may vary depending upon the desired properties sought to be obtained by the present invention. Unless otherwise indicated, the term “at least” preceding a series of elements is to be understood to refer to every element in the series. Those skilled in the art will recognize, or be able to ascertain using no more than routine experimentation, many equivalents to the specific embodiments of the invention described herein. Such equivalents are intended to be encompassed by the following claims. 

The invention claimed is:
 1. A method for eliminating or substantially reducing non-Hodgkin's lymphoma in a subject comprising administering a) a lymphocytotoxic but hematopoietic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug without combination chemotherapy, b) an effective amount of a monoclonal antibody consisting of a monoclonal antibody that selectively binds to a B-cell specific antigen and depletes or substantially reduces B cells to the subject, and not transplanting stem cells, such that the subject's immune system reconstitutes without stem cell transplantation, c) an effective amount of an autologous anti-idiotypic vaccine, d) an effective amount of a hematopoietic growth factor pegfilgrastin, and e) an effective amount of Mesna, thereby to eliminate or substantially reduce non-Hodgkin's lymphoma in the subject.
 2. A method for eliminating or substantially reducing a B cell derived cancer in a subject comprising administering a) a lymphocytotoxic but hematopoietic stem cell sparing high-dose pulsed amount of an oxazaphosphorine drug without combination chemotherapy, b) an effective amount of a monoclonal antibody consisting of a monoclonal antibody that selectively binds to a B-cell specific antigen and depletes or substantially reduces B cells to the subject, and not transplanting stem cells, such that the subject's immune system reconstitutes without stem cell transplantation, c) an effective amount of an autologous anti-idiotypic vaccine, d) an effective amount of a hematopoietic growth factor pegfilgrastin, and e) an effective amount of Mesna; thereby eliminating or substantially reducing the B cell derived cancer in the subject.
 3. The method of claim 2, wherein the B cell derived cancer is selected from the group consisting of non-Hodgkin's lymphoma, Hodgkin's lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma and multiple myeloma.
 4. The method of claim 2, wherein the oxazaphosphorine drug is selected from the group consisting of cyclophosphamide, ifosfamide, perfosfamide, trophosphamide (trofosfamide), or a pharmaceutically acceptable salt, solvate, prodrug and metabolite thereof.
 5. The method of claim 2, wherein the oxazaphosphorine drug is cyclophosphamide or a pharmaceutically acceptable salt, solvate, prodrug and metabolite thereof.
 6. The method of claim 2, wherein the monoclonal antibody selectively binds to CD-20.
 7. The method of claim 2, wherein the monoclonal antibody selectively binds to CD-22.
 8. The method of claim 2, wherein the amount of the oxazaphosphorine drug is 50 mg/kg/day.
 9. The method of claim 2, wherein the oxazaphosphorine drug is administered to the subject for 4 days.
 10. The method of claim 2, wherein the oxazaphosphorine drug is administered at a dose of 50 mg/kg/day for 4 days.
 11. The method of claim 2, wherein the effective amount of the monoclonal antibody is selected from the group consisting of between about 100 mg/m² and 200 mg/m², between about 200 mg/m² and 300 mg/m² and between about 300 mg/m² and 400 mg/m².
 12. The method of claim 2, wherein the effective amount of the monoclonal antibody is about 375 mg/m².
 13. The method of claim 2, wherein the monoclonal antibody is administered to the subject before the administration of the oxazaphosphorine drug.
 14. The method of claim 2, wherein the monoclonal antibody is administered to the subject after the administration of the oxazaphosphorine drug.
 15. The method of claim 2 wherein the subject is a subject in whom immune tolerance to the cancer has been broken.
 16. The method of claim 2 wherein the subject is a subject who is being treated with a monoclonal antibody that selectively binds to a B cell specific antigen. 